Hip Tear Evaluation and Treatment
Start with plain radiographs (AP and lateral views) for initial evaluation, then proceed to MRI without contrast if you suspect a soft tissue tear (labral, tendon, ligament), or CT without contrast if you suspect an occult fracture after negative radiographs. 1
Initial Imaging Approach
Begin with hip radiographs (AP and lateral views) as your first-line imaging for any hip tear presentation 1. This establishes whether you're dealing with:
- Bony pathology (fracture, dislocation, FAI morphology)
- Soft tissue injury requiring advanced imaging
When Radiographs Are Negative or Indeterminate
The next imaging choice depends on your clinical suspicion:
For suspected soft tissue tears (labral, tendon, ligament):
- MRI hip without contrast is the gold standard 1
- MRI detects 100% of proximal hamstring avulsions (vs. only 58.3% for ultrasound) 1
- MRI is essential for gluteus medius/minimus tendon tears, iliofemoral ligament injuries, and ligamentum teres tears 1
- Ultrasound has insufficient evidence and limited utility for acute tears 1
For suspected occult fracture:
- CT without contrast is first-line due to speed and availability 1
- CT has 94% sensitivity and 100% specificity for radiographically occult hip fractures 1
- CT finds occult fractures in 24.1% of cases with negative radiographs and changes management in 20% 1
- Critical caveat: If CT is negative but clinical suspicion persists, you still need MRI 1
Treatment Algorithm
Labral Tears
Begin with nonoperative management for 6 months minimum 2, 3:
Nonoperative treatment includes:
- Activity modification
- Targeted physical therapy focusing on hip stabilization
- Selective intra-articular corticosteroid injections for diagnostic and therapeutic purposes 2, 4
Prognostic factors predicting surgical need:
- Age (younger patients better surgical candidates)
- Severity of pain
- Presence of hip dysplasia
- Degree of degenerative changes
- Presence of FAI significantly increases likelihood of surgical intervention 4, 3
In adolescent athletes with labral tears, 68.4% received physical therapy and 72.4% received intra-articular injections, but those with concurrent FAI had significantly higher surgical rates 4.
Surgical indications after failed conservative management:
- Persistent mechanical symptoms (clicking, catching, locking, giving way) 5
- Functionally limiting pain despite 6 months of appropriate nonoperative care 2, 3
- Arthroscopic surgery prioritizes labral preservation through repair when viable, or reconstruction for irreparable tissue 2
- Correction of underlying FAI (CAM/Pincer morphology) is essential during surgery 2
Return to sport typically occurs at 6-8 months post-surgery but varies by sport demands 2, 3. Strong consensus exists that minimum 6 months should elapse before reinvestigation for persistent symptoms 3.
Gluteal Tendon Tears (Abductor Tears)
Surgical repair is indicated when:
- MRI confirms tendon disruption
- Clinical findings show chronic lateral hip pain
- Positive Trendelenburg sign present
- Failed conservative management 6
Surgical repair produces substantial and durable improvement, with mean Harris hip scores improving from 53 preoperatively to 88 at 5 years 6. Sixteen of 19 patients (84%) were satisfied and would undergo the procedure again 6.
Hamstring Tendon Avulsions
Acute proximal hamstring tendon avulsions require MRI evaluation as these benefit from surgical repair of both partial and complete avulsions 1. Most muscle belly hamstring injuries do not require MRI acutely 1.
Common Pitfalls to Avoid
Don't skip radiographs - Always start here to assess for FAI morphology and bony pathology 1
Don't rely on ultrasound for acute hip tears - It has insufficient evidence and misses 42% of hamstring avulsions and 21% of gluteal tears 1
Don't stop at negative CT for suspected fracture - If clinical suspicion remains high, proceed to MRI 1
Don't rush to surgery for labral tears - Minimum 6 months of appropriate nonoperative management is required first 2, 3
Don't ignore FAI morphology - Presence of FAI dramatically affects surgical decision-making and must be addressed during any labral repair 2, 4
Don't use contrast for initial CT or MRI - Noncontrast imaging is appropriate for soft tissue tears and occult fractures 1